Provider:
Lincolnshire Partnership NHS Foundation Trust
Good

Inspection Summary

Overall summary & rating

Good

Updated 16 January 2019

The trust responded in an extremely positive way to the improvements we requested them to make following our inspection in April 2017. At this inspection, we saw significant improvements in the core services we inspected and an impressive ongoing improvement and sustainability of good quality care across the trust as a whole. The senior leadership team had been at the fore front of delivering quality improvement and there was a true sense of involvement from staff, patients and carers towards driving service improvement across all areas.

Leadership had been invested in at all levels so that staff had the right skills, behaviours, knowledge and experience to challenge as necessary and to ensure quality and sustainability of service delivery. This was underpinned by a very strong senior leadership team that had identified priorities, driven cultural change at a pace and led by example. The trust board and senior leadership team displayed integrity on an ongoing basis. The trust’s non-executive members of the board challenged appropriately and held the executive team to account to improve the performance of the trust. The trust leadership team had a comprehensive knowledge of current priorities and challenges and took action to address them. The board were supportive to the wider health and social care system, with both the chair, chief executive and executive team taking up key roles in the local system including through Sustainability Transformation Programme. Reports from external sources, that include NHS Improvement and commissioners, was consistently favourable.

The trust had a clear vision and set of values with quality and sustainability as the top priorities which were robust and realistic. These had been co-produced with staff at all levels and patients. Values were fully embedded throughout the trust through recruitment, new initiatives, staff appraisals and staff wellbeing. At board and committee meetings discussions were consistently linked to the values. We were particularly impressed that each service had identified specific behaviours that aligned with each value so they had close alignment with their services. Each individual team across the trust had taken time to ensure that they understood what the values and behaviours meant for their individual teams and the patients that they provided care for. Local leadership across the trust was strong, visible and effective. Staff were particularly praising of the chief executive and the chair of the trust.

We found that there has been a continued and impressive cultural shift to an organisation that is truly inclusive, that enabled and empowered staff and patients to be heard and became part of the culture of change. The culture had truly been embedded and promoted an arena across the trust for shared learning and encouragement of staff to offer ideas to improve service delivery and patient experience. Staff showed pride and spoke passionately about their roles and working for the trust, their personal progression, opportunities to access specialist training and open and transparent relationships with senior colleagues.

The building of a continuous quality improvement and innovation culture has enabled the trust to move from a top down organisation to a system where staff were empowered to make decisions for improvement for the benefit of services to patients. The delivery of innovative and continuous quality improvement was central to all aspects of the running of the service. There was a true sense of desire to drive service improvement for the benefit of patients, carers, and the wider system, evident throughout the inspection. Staff included patients in service improvement and used their feedback to change practice. The trust actively sought to participate in national improvement and innovation projects, and encouraged all staff to take ownership, put forward ideas and remain involved throughout the process. The trust had improved their focus and the attention that they paid to innovation in the last 2 years which had yielded positive outcomes and national awards. Research was acknowledged as an asset in the trust. For the first time in 2018 the research annual report and outcomes was published highlighting the excellent work done across the organisation. The trust was proud to highlight the research and innovation conference which was attended by nearly 100 attendees. The conference encouraged staff to take their first step on research and understand what research can mean for them.

Engagement with both staff and patients was evident and was seen to be fundamental to the way that the trust makes decisions, changes and manages the services. Peer support workers, experts by experience and clinical apprentices were not only valued in teams but part of them and strengthen the voice and the participation of the patients. The trust had invested in these patients and provided training and mentorship to them. Staff, patients and carers were actively involved in a number of different ways and the trust prioritised engagement at every level and through all services. Patients, families and carers were encouraged to provide feedback on the care they had received by a number of routes, for example, via focus groups, questionnaires and a variety of engagement events.

Staff across all services spoke highly of the executive team and chair without exception. We observed that the vision and values of the organisation were truly embedded throughout the trust and reflected in all aspects of care delivery; including service re design. The commitment to equality and diversity was exemplary. The equality strategy had been produced to clarify the intentions and obligations of the trust and to openly show their commitment to equality and diversity. We were told about several examples of how the views of the members of the networks and individuals were fully integrated into defining the tone and philosophy of the trust. Throughout the year the trust had held equality Conferences to raise awareness of equality areas, jointly with Lincolnshire NHS providers and internal staff networks. The trust was proud to share with us the progression of the multi-agency LGBT+ conference. Staff network groups provided a platform for staff to voice their opinions and support the trust to improve working practices and services.

Staff showed caring, compassionate attitudes, were proud to work for the trust, and were dedicated to their roles. We were impressed by the way all staff in the trust embraced and modelled the values. The values were embedded in the services we visited, and staff showed the values in their day-to-day work. Throughout the trust, staff treated patients and each other with kindness, dignity and respect. The style and nature of communication was kind, respectful and compassionate and met the needs of the individual patients. Staff showed strong therapeutic alliances with their patients and carers and clearly understood their needs and wishes. Staff offered guidance and caring reassurance in all therapeutic interventions, but they were in particularly inspiring and skilled when they supported patients that felt unwell or distressed, confused or agitated. Overall, positive feedback was received from those patients, families and carers spoken with about the care and treatment received from staff. Patients told us that they felt safe across the trust. The trust promoted a person-centred culture and staff involved patients and those close to them as partners in their care and treatment. Staff provided positive emotional support to patients.

The trust had robust systems and processes for managing patient safety. Staff recognised when incidents occurred and reported them appropriately. The board had oversight of incidents, and themes and trends were identified and acted upon. Managers investigated incidents appropriately and shared lessons learned with staff in a number of ways. When things went wrong, staff apologised and gave patients honest information and suitable support. The trust applied the duty of candour appropriately. We reviewed serious incident reports and found investigations were thorough and included participation from family and carers; where appropriate. Staff had training on how to recognise and report abuse and applied it. The trust had effective systems for identifying risks and planning to eliminate or reduce them. We were particularly impressed with the trust focus on reducing dormitories style accommodation in the inpatient services. The trust was committed to improving services by learning from when things go well and when they went wrong.

The management of risk and the use of data has significantly improved since our last inspection. Data was being turned into useful information for all levels of staff to use to inform practices. We were impressed with the trust decisive and swift move from a RAG rating system of reporting to a statistical process control technique. In addition, this they had also implemented NHS Improvement summary icons to indicate the type of variation seen on each reporting indicator. This proactive and positive change has enabled the board to focus on changes in performance which merit discussion and potential interventions required.

The board had listened to staffs’ feedback about the patients’ electronic record and invested in replacing the system. The new system went live in September 2018. The new system supported staff to maintain clear records of patients’ care and treatment and ensured patient confidentiality was maintained. Staff we spoke with were pleased with the new system and felt the trust had delivered quality training to support them to use it. Whilst they acknowledged that it was still early days using the system they had all noted that the system was a vast improvement and supported them in their day to day work. Care and treatment records were clear, up-to-date and available to all staff providing care. The trust provided care and treatment based on national guidance. Patients had access to psychological support and occupational therapy. The physical healthcare needs of all patients were met. Patients that were admitted to acute hospitals were supported by mental health and learning disability practitioners during their admission and throughout the discharge process.

Staff were compliant with mandatory training across all services and staff had opportunities for further training to support care and treatment for patients. Managers ensured staff received supervision and yearly appraisals.

The trust ensured safe staffing levels were maintained. Staffing levels and skill mix across all core services was planned and reviewed so that people who used services received safe care and treatment. Managers ensured services across the trust increased staffing based on clinical need or made arrangements to cover leave, sickness and absence.

Trust premises across all mental health and community teams were clean and well maintained. Across services staff had completed environmental risk assessments. Where issues had been identified, staff mitigated these risks by carrying out additional checks or had taken other actions to resolve the issues. The trust had robust estate management processes and ongoing plans for improvements.

The trust had a clear oversight and had promoted the importance of wellbeing amongst their workforce. The wellbeing service demonstrated the responsiveness of the organisation to support the wellbeing of staff. The service had a dedicated psychological and occupational therapy service which included a dedicated counsellor for staff experiencing domestic abuse. Staff we spoke with throughout the inspection spoke highly of the wellbeing service and acknowledged that the trust had worked hard to deliver a service that met the diverse needs of the staff that worked across the trust.

We were pleased that the trust had reviewed the appropriateness of the governance arrangements in relation to the Mental Health Act administration and compliance. They had recognised that this was a key area to strengthen to ensure the best possible outcomes for patients detained under the Mental Health Act. This review led to the implementation of a policy document and flowchart being devised and implemented in both clinical division and corporate teams to highlight the correct procedure for the administration of the Act. Heat maps were produced to identify to teams the proactive reading of patients’ rights, reviews of sections and the completeness of the detention paperwork. Audits for Mental Health Act and Community Treatment Orders were clearly documented.

Systems for the safe management and administration of medicine were in place. Incidents and errors within the trust were reported and investigated and outcomes and learning shared with staff. The pharmacy team were now involved in the reviewing of serious incidents when medicines were involved.

However:

The trust continued to have difficulties in recruiting substantive consultant and medical staff. It remained above the budget of medical agency expenditure to cover consultant vacancies.

The recording of staff supervision remained an issue. Whilst we recognise that, since the last inspection, the trust had taken action in order to promote staffs experience and compliance with supervision, the recording systems were not robust and did not capture staffs’ compliance with supervision. However, we note the compliance figures were on an upward trajectory and were confident that this would continue to increase.

In the near future they were going to be some very significant changes in the senior leadership team in the upcoming months. Whilst we acknowledge how this is being thought through, planned and managed over time, we have some concern that this could potentially be de-stabilising.

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Inspection areas

Safe

Good

Updated 16 January 2019

Our rating of safe stayed the same. We rated it as good because:

The trust had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Community patients had rapid access to a psychiatrist when needed. Inpatient services had the appropriate medical cover throughout the day, and an on-call rota in place throughout the night. Each ward manager adjusted staffing levels daily as required, to meet patient needs. When necessary, bank and agency staff were sought to maintain safe staffing levels.

Staff used recognised risk assessment tools or adapted tools. Staff completed holistic risk assessments on admission and updated these regularly and after incidents. Staff used the assessment to understand and manage risks individually. Ward staff responded to changes in patient risks.

Staff understood how to protect patients from abuse and were aware of the requirement to work well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. The training was at the appropriate level for the services they delivered.

The service had a good track record on safety. Staff managed service user safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave service users honest information and suitable support.

Staff received and were up to date with mandatory training. Specialist training and leadership training was available.

Staff followed best practice when storing, giving, and recording medication, and staff regularly reviewed the effects of medications on each patient’s physical health. Patients detained under the Mental Health Act received medicines that were duly authorised and administered in line with the Mental Health Act Code of Practice. Staff had access to T2 (consent to treatment) and T3 (record of second opinion) for reference when administering medication for patients.

Clinical areas were safe, clean, well furnished, well maintained and fit for purpose. Staff could see all clinical areas and knew about any ligature anchor points and the actions to mitigate risks to patients who might try to harm themselves. Ligature cutters were available in service areas.

However:

We found two environmental issues in the seclusion rooms at Ward 12 and the Hartslome centre, managers told the inspection team the trust was addressing these.

Emergency medicines were available within the acute wards; however, they were locked in the drug cupboard which may have caused a delay in administration.

We could not be sure that staff in the community teams would be able to access emergency aid in all situations, in a timely manner. Neither did staff have access to emergency adrenaline, if needed, when administering medications at the service users home.

In one of the eight community adult mental health teams we visited staff were not recording clinic room temperatures in line with trust policy.

In the community adult mental health teams Doctor’s caseloads were higher than national guidelines suggested they should be. Doctors told us they did not feel confident that there were enough or appropriate resources either within or external to the service to enable them to discharge.

Demand for the community and home treatment team had increased over the last few months and staff told us that if this continued current staffing levels would not be sufficient.

Staff were able to access information but not always in a timely manner. The trust had recently transferred to a new electronic record system. At the time of our visit there were three systems in use; the new system, the previous system and a temporary system to bridge the two.

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Effective

Good

Updated 16 January 2019

Our rating of effective improved. We rated it as good because:

Staff assessed the physical and mental health of all service users on admission and supported service users with their physical health and encouraged them to live healthier lives. Staff developed individual recovery focussed care plans and updated them when needed. Staff provided treatments and care for service users based on national guidance and best practice. Staff had implemented positive behaviour support plans for patients with behaviours that challenge.

Staff kept detailed records of service users care and treatment. The new care records were recovery orientated and reflected the service users’ views and goals. They were clear, up-to-date, and easily available to all staff giving care. Care plans included protection plans and vulnerabilities where applicable. Staff could give examples of how to protect patients from harassment or discrimination; including protected characteristics under the Equality Act. The trust had implemented interactive technology at the Hartsholme centre which enabled patients to have access to their care plans in electronic form in their bedroom.

A physical health lead supported staff to ensure patients received the support they needed for physical health care. Acute liaison nurse who supported patients when they accessed acute health care.

Managers made sure they had staff with the skills needed to provide high-quality care. They supported staff with appraisals, supervision, opportunities to update and further develop their skills. Other specialists, such as a speech and language therapist or dieticians, could be accessed via a referral. The trust was supporting some nursing assistants to undertake nurse training. Qualified nurses were encouraged to attend additional training and conferences.

Staff in the community learning disability team had effective working relationships with external teams and organisations. This included with the local authority, the acute hospital, schools and other providers. Representatives from the local authority attended hub team multi-disciplinary meetings. The service had developed a joint protocol with the local acute hospital trust for supporting patients with learning disabilities.

Managers had recognised the need for specialised roles within teams. They provided opportunities for peer support workers, people with lived experience of mental health illness to take on roles to help service users back into education, employment, and productivity. They had also trained peer support workers to jointly facilitate psycho-education groups for people experiencing bi polar disorder.

Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice. Managers made sure that staff could explain to service users their rights. Staff supported service users to make decisions on their care for themselves. They understood the trust policy on the Mental Capacity Act 2005 and assessed and recorded capacity. The service had its own Mental Act administrators who checked Mental Health Act and Mental Capacity Act paperwork, and they had completed an audit of this paperwork in May 2018.

However:

Staff at the south west hub community adult team, had not recorded detailed assessments of patients’ mental capacity. Records of mental capacity were not always easy to find due to different systems being in use at the time of the inspection.

In the community adult team not all staff had completed Mental Capacity Act training. Staff compliance with Mental Capacity Act training was 76%, which was lower than the 87% reported at the last inspection.

We reviewed 41 seclusion records, 18 (46%) patients did not have a medical review within one hour of their episode of seclusion commencing and nine (24%) of the records examined did not have a specific seclusion care plan.

Whilst on site managers told us that supervision compliance rates had improved, the recording of staff supervision remained an issue. Supervision rates for the staff within the acute services were at 70% and the learning disability community team rate was 76%. Both compliance rates were below the trust target of 85%.

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Caring

Good

Updated 16 January 2019

Our rating of caring stayed the same. We rated it as good because:

We found patients, families and carers were truly respected and valued as individuals across all services.

We were impressed throughout the inspection on how staff treated service users with compassion and kindness. When interacting with service users they were respectful and responsive providing service users with help, emotional support, and advice at the time they needed it. Staff respected service users’ privacy and dignity.

The trust had worked hard to produce a strong, visible and person-centred culture. Staff were highly motivated and delivered kind and compassionate care; which respected the individual choice of patients and protected their dignity. Staff recognised and respected the individual needs of patients, including cultural, social and religious beliefs.

Staff made sure patients understood their care and treatment (and found ways to communicate with patients who had communication difficulties). One carer told us that staff had provided their relative with a communication passport. Another carer told us that staff used visual aids to communicate with their relative.

When patients were admitted to inpatient wards staff were orientated them to the ward. Staff showed patients around and introduced them to other staff and patients. Staff provided patients with welcome packs upon admission. This contained information about the ward generally and the patients’ rights, whether detained or informal, this was available in electronic format at the Hartsholme centre.

Through the trusts engagement programme staff ensured patients, families and carers had the opportunities to be active partners in their care. Staff across the organisation worked in partnership with patients and those close to them in an integrated approach. We saw this had a positive impact on patient care.

The trust ensured patients and carers could provide feedback on the services they received in a number of ways. For example, involvement in focus groups and patients’ engagement meetings. In the patient friends and family test.

Staff ensured that patients could access advocacy, both within the trust and from an independent advocacy service. Carers were provided with information on how to access a carer’s assessment. Carers felt supported by staff and involved appropriately in their relatives’ care and treatment.

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Responsive

Our rating of responsive stayed the same. We rated it as good because:

People could access services when they needed to. Within the community health services, waiting times from referral to treatment were in line with good practice.

Bed management processes were effective and included daily bed management meetings. Managers said they would endeavour to ensure a bed was available for patients on return from leave. Patients were not moved between wards during an admission episode unless it was justified on clinical grounds, for example a transfer to the psychiatric intensive care ward.

Staff responded to referrals in a timely manner. The hub teams held weekly referral meetings to review new referrals. We observed one of these meetings, referrals were received from GP’s, other providers, the local authority and other trust teams. Staff decided as a multi-disciplinary team whether the referral met the service criteria and it was then allocated to the discipline of staff best placed to meet the patients’ needs.

Within the mental health and learning disability community teams, the services had a clear admission and discharge criteria. Staff monitored any service users on waiting lists for assessment through weekly telephone calls from duty workers, and the service user knew how to access urgent help if needed. Service users could access the service closest to their home when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge service users were in line with good practice. Staff saw urgent referrals quickly, and non-urgent referrals within an acceptable time.

Staff across the acute and psychiatric intensive care unit service worked on admissions and discharges. Bed managers, social workers and discharge co-ordinators all worked collaboratively to ensure appropriate flow of movement across the acute and psychiatric intensive care units.

Since the last inspection there has been a significant decrease in patients placed out of area. The opening of the male psychiatric intensive care unit (PICU) contributed to this. Since it opened in July 2017 no male patients requiring this service have been placed out of county. The trust produced a daily dashboard of patients in out of area placements which was monitored and arrangements for patients to return to local beds was discussed. At the time of the inspection we were informed there were 21 out of area placements.

The service was accessible to all who needed it and took account of service users’ individual needs. Staff helped service users with communication, advocacy, and cultural support.

The service provided information in a variety of accessible formats, so the patients could understand more easily. The service provided information in line with accessible information standards. Managers made sure staff and patients could get hold of interpreters or signers when needed.

Staff and inpatients had access to a full range of rooms and equipment to support treatment and care. Each ward had space utilised for activities, clinic rooms and de-escalation rooms. In addition to this, outside space was available for fresh air. The service also had gyms for patient use, following an appropriate induction.

Within the community teams there were enough interview rooms, therapy rooms, and clinic space for staff to see service users in comfort. There were adequate resources at the team bases to enable staff to deliver the treatments necessary. Staff supported service users with activities outside the service, such as work, training, education, and family relationships.

Patients we spoke with were aware of how to make a complaint, and who to approach in the first instance. Staff managing the complaint usually fed back the findings to the patients. This could be face to face, if the patient was on the ward, or through a letter. Staff knew how to handle complaints appropriately, and knew how to escalate, where to record, and who to report too.

However:

The trust were commissioned to provide a service that diagnosed autism spectrum disorders but did not offer any support. The trust had inherited a waiting list for this service, which was at 211 at the time of our visit.

The number of readmission to this the acute and psychiatric intensive care unit had increased. In the 12 month period 1 January 2016 to 31 December 2017 there was 32 readmissions within 28 days. For the 12 month period 1 May 2017 to 30 April 2018 there was 71 readmissions within 28 days of discharge.

Child and adolescent mental health wards

The ward was clean, tidy and well maintained. Observation mirrors and closed circuit television was used to assist nursing staff with observations.

The ward had an up to date ligature risk audit, staff mitigated the risk on the ward by observing patients. Staff mitigated the risks posed in the garden area by accompanying patients when they wanted to access the garden.

The ward had sufficient staff to provide good care and treatment to patients.

The ward met the criteria for eliminated mixed sex accommodation in line with guidance contained in the Mental Health Act code of practice.

Staff were 98% compliant for mandatory training.

Staff undertook a risk assessment with every patient upon admission. Care plans were comprehensive, personalised, holistic, and recovery orientated.

Staff provided a range of therapeutic interventions in line with the National Institute for Health and Care Excellence guidelines and there was a full education programme in place.

Staff read detained patients their rights on admission and regularly thereafter. Staff gave patients an information leaflet explaining their rights and responsibilities as an informal patient.

Overall, 100% of non-medical staff had an up to date appraisal.

There was a well-functioning multidisciplinary team. Staff discussed patients’ care and treatment weekly in ward round. Parents told us that they felt involved in the care and treatment.

Patients told us that they felt supported to make their own decisions and staff treated them with dignity and respect. Patients said they were involved in their care plan.

Staff interacted with patients in a positive way. All staff demonstrated a good understanding of patients’ individual needs, including care plans, observations and risks.

The ward had a range of rooms and equipment to support treatment and care. There was a large garden; with an area that had been made secure. Patients could personalise their bedrooms and could choose from a choice of bedding.

There was a family room for parents, carers and siblings to visit. Visits within the community and the garden area were also encouraged.

There was access to activity across the week with primarily nurse led sessions over the weekend. Patients worked with the activity coordinator to plan activities that they would like to do.

All staff demonstrated the trust values in their behaviour and attitude. Staff we spoke with were passionate about helping patients with mental illness. Staff were proud of the work that they carried out and the care that they provided to patients.

Managers told us they had sufficient authority to complete their role and they felt supported by senior managers.

However:

Staff kept most doors on the ward locked. There was no clinical justification for this practice and it was not individually care planned. This was a blanket restriction.

Seventy-one per cent of staff had undertaken training in clinical risk assessment and management. This was below the trust target of 95%.

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Specialist community mental health services for children and young people

Outstanding

Updated 9 June 2017

We rated Lincolnshire Partnership NHS Foundation Trust specialist community mental health services for children and patients as outstanding because:

Patients and carers told us that everyone was caring, compassionate, kind and treated them in a respectful manner. All feedback surveys collected by the trust were consistently positive about the way that staff treated patients.

The service had established an innovative model of working using outcome measures at each appointment. This model was patient centred and holistic based around the child or young persons’ strengths and goals.

Staff were open and transparent in relation to incidents and complaints. They acted on lesson learnt from incidents and complaints. They strived to continually improve the service they delivered by working closely with commissioners and other stakeholders.

Managers and senior staff including board members were visible and approachable. Staff expressed they felt able to raise concerns without fear of reprisal. The managers and team co-ordinators were passionate about delivering high quality care and treatment and had funded 17 clinicians to undertake children and young people’s improving access to psychological therapies training. They had managed to recruit to the 17 vacancies with substantive posts therefore increasing the level of staffing within the service.

Risk assessments and care plans were comprehensive and well written. They were developed in collaboration with the patient and, where appropriate, their carers. Staff were able to refer patients to the crisis and home treatment and resolution service within CAMHS if they were concerned about a young person’s presentation out of hours and at weekends. This service had been praised highly by senior staff at the local hospitals in relation to the responsiveness of the team Communication between the teams was excellent.

The service had introduced an animal assisted therapy service to group work for patients.

However:

Only 68% of staff had undertaken the children’s safeguarding training level 3B.This was below the trust target of 95%.

Staff supervision rates were lower than the trust expectations and managers did not always keep a record of supervision sessions.

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Forensic inpatient/secure wards

Good

Updated 9 June 2017

We rated forensic inpatient/ secure units as good overall because:

Francis Willis was a slightly dated but pleasant environment. There were clear lines of sight throughout the ward. The trust has completed detailed ligature risk assessments and plans were in place to appropriately manage these risks within the unit.

The defibrillator and essential safety equipment had been serviced and regular checks were undertaken.

There was sufficient staffing during weekdays and the unit had medical support at all times. Staff had undertaken mandatory training and received regular supervision and appraisal

Nursing staff on the wards were enthusiastic in their approach and patients spoke positively about them. The clinical team contained full multi-disciplinary representation.

All admissions were planned following pre admission assessments. Local risk assessments were also carried out after admission. Patient care plans were personalised and based around the individualised risk.

All patients had their physical healthcare needs met and there was an effective health care recording system

Leadership on the unit was highly visible and managers had a positive presence on the ward.

Areas of concern highlighted following our previous inspection had been addressed.

However:

We remain concerned about the safety of the garden area of the ward. This contained potential ligature points and additional safety risks that had not been addressed through environmental risk management plans. Staff managed these risks through restricting patient access.

We found some other examples of blanket restrictions. These included access to mobile phones and set vaping times.

While patients had a good level of activity and escorted leave during weekdays there were limited activities available at weekend.

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Community-based mental health services for older people

We rated community based community mental health services for older people as good because:

All patient information was stored electronically and was accessible to staff.

The service followed National Institute for Health and Care and Excellence (NICE) guidance in prescribing medication and reviewing patients who had dementia.

Patients were consistently positive about the centres and about the staff, patients felt understood and cared for.

Patients told us that they felt involved in their care planning and that they had been offered a copy of their care plan.

Staff were able to prioritise and see urgent referrals quickly.

There was a safeguarding champion available to support staff with safeguarding concerns and safeguarding posters were displayed in the reception areas at each of the locations.

Staff learned from incidents, complaints and patient feedback via the bi monthly lessons learned bulletin, at team meetings and during supervision. We saw examples of lessons learned and changes in practice as a result of this.

Leaflets were available in different languages and information was available in different formats on request.

Staff were passionate about their jobs and used the trusts’ vision and values in their everyday work.

Senior managers were visible and known to staff. They visited the locations to update staff on changes within the service and the trust.

Sickness and absence rates were low and clear strategies were in place to cover any staffing shortfalls.

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Wards for older people with mental health problems

Good

Updated 9 June 2017

Ligature points (places to which patients intent on self-harm might tie something to strangle themselves) were identified as part of the monthly environmental risk assessment audit and actions had been identified to reduce the risk to patients. These included enhanced observation levels. Wards complied with the Department of Health’s eliminating mixed sex accommodation guidance, which meant that the privacy and dignity of patients was upheld.

Cleaning rotas had been completed and the wards were visibly clean and tidy. Nurse call systems were in place in bedrooms, communal and office areas.

Staffing levels were appropriate to meet the needs of patients. There were low levels of both qualified and unqualified nursing vacancies. Ward managers were able to adjust staffing levels to take account of clinical need and said senior managers never refused a request for additional staffing if required. Escorted leave and activities were rarely cancelled due to staff shortages.

Staff followed National Institute for Health and Care Excellence (NICE) guidelines in relation to practice and when prescribing medications. These included regular reviews and physical health monitoring. Patients were supported to access specialists when required for physical healthcare needs. Hydration and nutrition were monitored regularly and recorded in care records.

Staff and patients interacted well. Staff managed distressed patients in a calm and responsive way and supported them to talk about the issues affecting them. Staff knew the patients very well and were passionate about patients' needs. Patients told us that they had good relationships with staff and they were very helpful, understood their problems and were always available. They said they felt safe and that staff took the time to listen to them when they had a problem.

Hot drinks and snacks were available on request 24 hours a day. Patients were able to personalise their bedrooms.

Staff told us who the most senior managers in the trust were and that they had visited the wards. Ward managers told us they felt well supported by their line managers.

However:

Staff did not always review risk assessments following incidents.

There was limited access to psychological therapies. The service had one whole time consultant psychologist and one whole time assistant psychologist for both community and inpatient older adult services.

Trust data showed supervision rates across the service between January 2017 and March 2017 to be 66%. The trust could not be assured that performance issues and training needs were identified or acted upon.

Capacity assessments were not decision specific, forms included more than one question.

One patient was receiving covert medication, we did not find a capacity assessment form for this.

There was little evidence of patient participation in care plans and risk assessments. Four patients reported that they had not seen or been provided with a copy of their care plan.

Patients had a lockable drawer in their bedroom; however keys were not available for patients to lock the drawer.

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Long stay or rehabilitation mental health wards for working age adults

Good

Updated 9 June 2017

We rated Long stay/r

ehabilitation on mental health wards for working age adults as good because:

All wards had detailed ligature risk assessments. Staff knew where the risks were and how they should manage them. Patients said they felt safe on the ward.

The majority (94%) of staff had received training in safeguarding adults and were able to identify what abuse was.

We looked at 15 patient records. The multidisciplinary staff team completed thorough, detailed assessments prior to and on admission. Staff updated these regularly.

We saw staff treating patients with kindness and understanding.

There were programmes of activities, both on and off the wards, with weekly plans for each patient. The service offered a programme of paid work opportunities for patients. These included jobs as a gardener and car valet. There was a patient run café at Discovery House. The café had recently employed a previous patient in a contracted paid role.

Patients had access to independent mental health advocates. There were posters displaying this information on noticeboards in the ward. Staff asked all patients if they would like to be referred to the advocacy service.

Staff were able to describe how they would apply the principles of the Mental Capacity Act in their roles. Patients had decision specific capacity assessments in their care records.

Ten patients said they were aware of how to make a complaint and would be able to do so if they felt they needed to.

Staff used a range of tools to measure patient outcomes. These included the recovery star, depression ratings, clustering and national early warning scores.

Morale within all teams was high. Staff worked well together within a multi-disciplinary approach.

Managers carried out audits of their ward performance, care records and safeguarding.

The service had participated in the Accreditation for Inpatient Mental Health Service (AIMS). All wards had been accredited as excellent up to October 2017 when the review was due.

However:

At the time of our visit, Vale ward reported a vacancy rate for qualified staff of 15%. The manager advised she had raised this as a risk issue and had put forward a proposal to block book regular agency staff to keep staffing levels safe.

Staff raised concerns at Maple Lodge about medical cover not being sufficient.

Supervision rates were slightly below the trust target of eight supervisions a year in two of the five wards.

On two wards food fridge temperatures were above the acceptable range.

Mental health crisis services and health-based places of safety

The trust had taken actions to improve the environment of the health based place of safety and to increase the range of multi-disciplinary staff in crisis teams following our last inspection.

Staff completed risk assessments for all patients and updated them as the level of risk changed.

Many patients felt their mental health had improved as a result of the service they received from the crisis and home treatment teams.

The trust took action to address the changes to the Policing and Crime Act 2017 and had identified inpatient beds to ensure patients were not kept longer in the health based place of safety than needed.

Managers reviewed discharge processes for inpatients to ensure they did not remain in hospital longer than was needed. For example, they reviewed the use of the crisis house, improved communication with discharge coordinators and bed managers.

The trust arranged crisis team support based out of hours with the police to signpost patients to mental health services.

The trust met commissioned targets for contacting patients within four hours.

The trust had plans to develop a clinical decisions unit in 2018 to further support patients in crisis needing hospital admission.

Grantham crisis and home treatment team had achieved the Royal College of Psychiatrists home treatment accreditation scheme.

However

The trust had not ensured that staff regularly received clinical and managerial supervision.

Patients and carers did not have copies of their care plans explaining the support teams would give them.

Staff did not consistently document that they had assessed patients’ physical health care needs.

Crisis team staff said that patients could wait for hours to be transferred to out of area placements due to delays with the contacted transport service being able to respond and escort them.

Crisis teams did not include psychologists which meant assessments of patients at the point of crisis were not fully multi-disciplinary.

Staff morale in Louth was lower than other teams because of increased work due to the community mental health teams and difficulty accessing medical cover.

The trust had not ensured that all staff completed mandatory training for their role.

Trust information from April 2016 to March 2017 showed staff had not completed the patient’s discharge time on records on 127 occasions.

Inspection ratings

We rate most services according to how safe, effective, caring, responsive and well-led they are, using four levels:

Outstanding – the service is performing exceptionally well.

Good – the service is performing well and meeting our expectations.

Requires improvement – the service isn't performing as well as it should and we have told the service how it must improve.

Inadequate – the service is performing badly and we've taken enforcement action against the provider of the service.

No rating/under appeal/rating suspended – there are some services which we can’t rate, while some might be under appeal from the provider. Suspended ratings are being reviewed by us and will be published soon.

Ticks and crosses

We don't rate every type of service. For services we haven't rated we use ticks and crosses to show whether we've asked them to take further action or taken enforcement action against them.

There's no need for the service to take further action. If this service has not had a CQC inspection since it registered with us, our judgement may be based on our assessment of declarations and evidence supplied by the service.

The service must make improvements.

At least one standard in this area was not being met when we inspected the service and we have taken enforcement action.